Pelvic Floor Rehab After Childbirth: Who Needs It, When and How

A burst of laughter, a sneeze, a dash down the street to catch your older child, and a few drops escape. Or a feeling of heaviness low in the belly at the end of the day. After a birth, these signs are common, and they have an explanation: the pelvic floor has been stretched, sometimes torn. Pelvic floor rehabilitation is about giving it back its strength.

Do all women need sessions? When should you start, and with whom? Recommendations vary from country to country, and understanding why helps you decide. Here are the essentials, and the exercises to do at home.

What is the pelvic floor for?

The pelvic floor (the perineum) is a set of muscles that closes the bottom of the pelvis, like a hammock. Three openings pass through it: the urethra, the vagina and the anus. It supports the bladder, the womb and the bowel, and lets you hold back urine, wind and stools.

During pregnancy it carries a growing weight. In labour it stretches enormously, and it can tear or be cut, as our article on episiotomy and tears explains. After the birth it often contracts less well. The Geneva University Hospitals (HUG) list the possible problems: a feeling of looseness in the vagina, reduced sensation, leaks of urine or stools, a dropping of organs (prolapse) or pain during sex. According to Assurance Maladie, a weakened pelvic floor left untreated can, in the long term, lead to incontinence or prolapse.

Signs that should alert you

• Urine leaks when you cough, laugh, sneeze, lift or run. They affect about one woman in three in the first months, according to the Quebec guide Mieux vivre, more often after a tear or the birth of a big baby.
• Leaks of wind or stools, or trouble holding them back.
• A feeling of heaviness low in the belly or in the vagina.
• Pain during sex, or reduced sensation.

In the first days these problems are common and mostly temporary. The HUG advise telling the midwife or doctor if leaks of urine or stools persist 30 days after the birth. The rest of the recovery is described in our article on your body after childbirth.

Rehab for everyone? Countries do not agree

On this point, recommendations differ:

• In France, the French obstetricians' college (CNGOF) does not recommend sessions for women with no symptoms at 3 months, for lack of studies showing a benefit. It does recommend them for urine leaks persisting at 3 months, whatever their type: at least 3 sessions guided by a therapist, combined with home exercises. Early rehabilitation, within two months of the birth, is not recommended. Assurance Maladie specifies that it is prescribed "if necessary" at the postnatal consultation, and carried out by a midwife or a physiotherapist.
• In Switzerland, the HUG offer it two to three months after the birth, in six to nine 30-minute sessions: contraction and relaxation exercises, biofeedback, which lets you see your contraction, and electrostimulation.
• In the United Kingdom and Quebec, the emphasis is on pelvic floor exercises that every woman can do at home, with referral to a physiotherapist in case of difficulty.

The CNGOF adds two useful points. Rehabilitation improves urine leaks in the short term, over a year, but not in the long term, beyond 6 years: the exercises should therefore become a habit. And for prolapse, guided sessions do no better than simple advice on contracting: they are recommended neither to prevent or treat it, nor for pain during sex. They are, however, recommended to treat anal incontinence.

In Morocco, talk to your gynaecologist or midwife at the postnatal visit, between 6 and 8 weeks. If they think it useful, they will refer you to a physiotherapist or a midwife trained in pelvic floor rehabilitation.

Exercises to do at home

The basic exercises need no equipment and no gym. You still have to contract the right muscles. Here is the method from the UK's NHS:

1. Find the muscles: squeeze as if holding back wind or the urge to pass urine, around the anus and then around the vagina, lifting inwards.
2. Long squeezes: squeeze and hold, no more than 10 seconds, then release completely.
3. Quick squeezes: squeeze and release fast, until the muscles tire.
4. The rhythm: build up gradually to 10 repeats of each exercise, at least 3 times a day.
5. Breathe normally, without holding your breath and without pulling in your belly.

Link them to a daily gesture, for example after each trip to the toilet or during a feed. From one month after the birth, the HUG also suggest exercises lying down with knees bent: contract the pelvic floor while breathing out and drawing in the lower belly, or gently lift the pelvis in a half bridge, holding for 5 to 10 seconds.

One method to avoid: the "stop-start" wee. Deliberately stopping the flow of urine to train can unsettle the bladder and increase the risk of a urinary infection, warn the HUG.

Protecting your pelvic floor day to day

The pelvic floor suffers from everything that pushes downwards. The HUG and Assurance Maladie give simple rules for the first weeks:

• Do not lift anything heavier than baby during the first month: no shopping, no water bottles, no older child on the hip.
• Do not strain on the toilet: knees higher than your hips, feet raised, body leaning forward. Eat fibre and drink enough to avoid constipation.
• Pass urine regularly, about every two hours in the first days, even without the urge.
• Avoid the handle above the bed to sit up in the maternity ward: each pull pushes on the organs and spreads the abdominal muscles.
• Postpone classic sit-ups: the NHS advises avoiding at first crunches, the plank and high-impact sports, especially if the abdominal muscles have separated, which our article on the belly after childbirth details.

When to go back to sport, and which one?

Gradually, listening to your body. The markers vary by source:

A simple marker, given by Naître et grandir: if you leak during effort, the pelvic floor is not ready yet. Go back to gentler activity and talk to your midwife or doctor. The return to sex, which often worries women when the area is sore, is covered in our article on sex after birth.